Inevitably our professional interests are shaped by the important learning events we experience and one compelling personal experience can have enduring consequences for our careers. My interest in clinical errors began at 7.00am one Sunday morning over 20 years ago. I was coming to the end of my night shift in charge of the Intensive Care Unit (ICU) when a cardiac arrest call came from one of the orthopaedic wards. Some minutes later the night sister called me, as the patient who had arrested had very recently been transferred from ICU. When I got to the scene I saw that the patient was indeed a man who had been transferred from ICU the previous day. Two very junior doctors were trying to orally intubate the patient in between efforts to ventilate him with a facemask.  Horrified, I told them that he had a permanent tracheostomy following laryngeal surgery some years previously. Placing the endotracheal tube into the tracheostomy stoma allowed good ventilation, but at least ten minutes had elapsed since the cardiac arrest and the brain damage was irreversible. The ward staff had all left the scene when the cardiac arrest team arrived and no one had alerted the doctors to the tracheostomy. The cause of the arrest proved to be obstruction of the tracheostomy tube by dried mucous, a totally reversible mishap, and the patient should not have died. This case was made even more memorable for me by my subsequent visit to the coroner’s court along with the two very frightened junior doctors.

We can learn two lessons from this tale of misadventure. Firstly, the sole anaesthetist in the hospital was in the operating theatre and unable to attend the cardiac arrest. This left airway management in the hands of two young doctors in their first few months of practice who had rudimentary skills . In emergency care we have many possible specialist teams: cardiac arrest teams, rapid response teams, ICU outreach teams. In many UK hospitals, because of the infrequent calls for such teams, and their call on scarce resources, the team members have additional duties. It cannot be presumed that a specialist team will always arrive on time, complete and able to efficiently fulfil its function.

Secondly, the ward nursing staff had left the scene upon the arrival of the cardiac arrest team and no one had told the doctors that the patient had a tracheostomy. This was a very significant failure; but were the nurses wholly at fault? The cardiac arrest protocol did not allocate a role to the ward nurses and no formal response was required from them in terms of support to the team. I have since seen this problem many times. The ward staff issues a call for the cardiac arrest team, who sweep into the ward and take over, usually with great efficiency. Frequently the ward staff do not know how to help. They are relegated to the role of spectator and it is not surprising that they take the opportunity to melt away, perhaps to call the family or to reassure other patients nearby.

For me, these lessons both pointed to similar conclusions. An emergency team may, in a real emergency, be missing key team members and it should be understood by all, that the team may not be fully effective. Also, the role of the ward team is to care for the patient, and this responsibility remains even when a specialist team is involved. The ward team know the patient, their medical and social backgrounds. They need to remain on the scene both to inform, and to assist in the continuing care of the patient. I saw that there seemed a gap in the system because there was no formal protocol, guidance or policy that allocated a role to the members of the ward team in the event of a cardiac arrest. If there had been physiotherapists this patient may have survived.

Healthcare increasingly uses specialists: nurses, pharmacists, etc. Concern is often expressed that this deskills the ward or unit team. Additionally liaison with specialist puts an additional step in the pathways of clinical communication. Whilst the activities of the specialist, individual or team are often carefully organised there is often little (or sometimes no) guidance for the regular carers about their relationship with the specialists. This deficiency led to the death of the patient I have described here and is still seldom recognised as a cause of error or as a patient safety risk. Whoops!